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rntc

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mm-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nVisual hallucinations\n \nMajor Surgical or Invasive Procedure:\nN/A\n\n \nHistory of Present Illness:\n___ male with ___ disease, dyslipidemia, and a\nhistory of prostate cancer (s/p prostatectomy) who was referred\nto the ED by his neurologist for worsening gait, falls, and\nvisual hallucinations. \n\nThe following history is taken from chart review: \n\nThe patient was seen by his neurologist on ___ at which time he\nwas noted to have visual hallucinations and worsening gait\nfreezing. For his gait freezing, his mirapex was increased by\n0.125 mg every week to a goal dose of 0.75 mg t.i.d. He\nsuccessfully up-titrated the medicine to 0.75/0.625/0.625 but\nbegan to have visual hallucinations and confusion so on ___ his\nneurologist recommended decreasing the dose to 0.625 TID. \nDespite\nthe changes to his Mirapex, the patient's daughter has noted\nprogressive gait stiffness and increased difficulty standing.\nThis has resulted in difficulty with simply getting to the\nbathroom leading to episodes of incontinence. A UA performed on\n___ was reassuring. \n\nOn the day of presentation to the hospital, the patient began to\nexperience visual hallucinations of a motor cross race in his\nbackyard. He subsequently had a fall while transferring from the\ncouch to a chair. His wife was unable to get him off the floor.\nThe fall was witnessed and there was no head strike. Per the\npatient's wife, his gait has acutely worsened over the past 24\nhours to the point where he has been unable to ambulate on his\nown. The patient's daughter called his neurologist who\nrecommended presentation to the ED. \n\nIn the ED, the patient was afebrile, HRs ___, normotensive, and\nSpO2 100% RA. On exam he was noted to have cogwheeling of upper\nextremities and decrease ___ strength. Labs were remarkable for a\nnegative urine and serum tox, Na 132, K 5.8 (hemolyzed and no \nEKG\nchanges), negative troponin, normal LFTs, unremarkable CBC. \nChest\nXray showed no acute process and CTH was reassuring. He was\nevaluated by neurology who recommended admission to medicine for\nfailure to thrive, to continue the patient's home medications,\nand complete a toxo-metabolic workup. The patient was given his\nhome pramipexole and pravastatin before he was admitted. \n\nOn arrival to the floor, the patient is comfortable in bed. He \nis\nnot accompanied by family on my interview. He knows that he is \nin\nthe hospital and that it is ___. He is not sure why he is here\nand begins to tell me about a party in his house with a motor\ncross race in his backyard. When I asked him about his fall, he\nmentions that he has not had a fall for ___ years. He denies any\nfevers, chills, cough, chest pain, abdominal pain, nausea,\ndiarrhea, or dysuria. \n\nREVIEW OF SYSTEMS:\n==================\nPer HPI, otherwise, 10-point review of systems was within normal\nlimits.\n\n \nPast Medical History:\n___ disease\n___ Body Dementia \ndyslipidemia \nprostate cancer (s/p prostatectomy)\n \nSocial History:\n___\nFamily History:\nHis mother died at age ___ of \"old age.\"\nHis father died of prostate cancer at ___. He has an older \nsister\n(age ___ and a younger sister (age ___. He has a younger \nbrother\n(age ___. As noted, he has 2 daughters. There is no family\nhistory of neurologic illness or dementia. There is no family\nhistory of neurodevelopmental mental disorders such as learning\ndisability or ADHD. There is no family history of psychiatric\nproblems.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: reviewed in OMR \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nBACK: No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone\nin LEs, ___ strength b/l ___. Normal sensation.\n\nDISCHARGE PHYSICAL EXAM\n======================\n24 HR Data (last updated ___ @ 2340)\n Temp: 97.7 (Tm 98.4), BP: 130/80 (130-153/80-90), HR: 80\n(80-104), RR: 18 (___), O2 sat: 100% (95-100), O2 delivery: Ra \n\n\nGENERAL: In no acute distress. Talking very quietly.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm.\nNEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone\nin LEs, ___ strength b/l ___. Normal sensation.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 10:30PM BLOOD WBC-8.6 RBC-4.03* Hgb-12.8* Hct-38.2* \nMCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt ___\n___ 10:30PM BLOOD Neuts-48.1 ___ Monos-15.9* \nEos-2.0 Baso-0.6 Im ___ AbsNeut-4.13 AbsLymp-2.86 \nAbsMono-1.36* AbsEos-0.17 AbsBaso-0.05\n___ 10:30PM BLOOD ___ PTT-23.4* ___\n___ 10:30PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-132* \nK-5.8* Cl-98 HCO3-19* AnGap-15\n___ 10:30PM BLOOD ALT-18 AST-38 AlkPhos-39* TotBili-0.4\n___ 10:30PM BLOOD Lipase-47\n___ 10:30PM BLOOD cTropnT-<0.01\n___ 10:30PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.0\n___ 10:30PM BLOOD VitB12-570\n___ 10:30PM BLOOD TSH-1.4\n___ 07:00AM BLOOD Trep Ab-NEG\n___ 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nIMAGING:\n========\n___ Imaging CT HEAD W/O CONTRAST \nFINDINGS: \nThere is no evidence of infarction, hemorrhage, edema, or mass. \nThere is \nprominence of the ventricles and sulci suggestive of \ninvolutional changes. \nThere is no evidence of fracture. The visualized portion of the \nremaining \nparanasal sinuses and middle ear cavities are clear. The \nvisualized portion of the orbits are unremarkable apart from \nbilateral lens replacements. \nIMPRESSION: \n1. No acute intracranial abnormality. No hydrocephalus. \n\n___ Imaging CHEST (PA & LAT) \nIMPRESSION: \nMild atelectasis in the lung bases without focal consolidation. \n\nAge-indeterminate moderate to severe compression deformity of a \nlow thoracic vertebral body. \n\nDISCHARGE LABS:\n===============\n___ 06:21AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.9* Hct-38.1* \nMCV-95 MCH-32.1* MCHC-33.9 RDW-12.8 RDWSD-44.4 Plt ___\n___ 06:21AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-140 \nK-4.0 Cl-104 HCO3-24 AnGap-12\n___ 06:21AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.___ male with ___ disease, dyslipidemia, and a\nhistory of prostate cancer (s/p prostatectomy) who was referred\nto the ED by his neurologist for worsening gait, falls, and\nvisual hallucinations concerning for progression of his\nneurologic disorder. \n\nACUTE/ACTIVE ISSUES:\n====================\n___ disease\n___ Body Dementia \n#Visual Hallucinations \nThe patient appears to have acute on chronic progression of his\n___ disease. Unclear if this is disease progression or\nunderlying medical cause. Continued mirapex, rasagiline, and \nrivastigmine. Neurology recommended started Seroquel for his \nhallucinations.\n\nHe was evaluated by physical therapy who recommended rehab. This \nrecommendation was discussed with the family who opted for \ndischarge to home with home physical therapy as this was in line \nwith the patient's goals of care.\n\nTRANSITIONAL ISSUES:\n[] f/u visual hallucination symptoms on Seroquel\n[] f/u physical therapy at home\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Rasagiline 1 mg PO DAILY \n2. Pramipexole 0.625 mg PO TID \n3. rivastigmine 9.5 mg/24 hr transdermal DAILY \n4. Pravastatin 40 mg PO QPM \n5. Cyanocobalamin Dose is Unknown PO DAILY \n6. Loratadine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. QUEtiapine Fumarate 25 mg PO QHS \nRX *quetiapine 25 mg 1 tablet(s) by mouth AT NIGHT Disp #*30 \nTablet Refills:*0 \n2. Loratadine 10 mg PO DAILY \n3. Pramipexole 0.625 mg PO TID \n4. Pravastatin 40 mg PO QPM \n5. Rasagiline 1 mg PO DAILY \n6. rivastigmine 9.5 mg/24 hr transdermal DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ Dementia\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were sent to the emergency room by your neurologist who \nwas concerned that you were having visual hallucinations.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were started on a new medication to help treat your \nsymptoms.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "G3183", "F0280", "R441", "R296", "E785", "Z8546" ]

[ "G3183: Dementia with Lewy bodies", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "R441: Visual hallucinations", "R296: Repeated falls", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate" ]

[ "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nomeprazole\n \nAttending: ___.\n \nChief Complaint:\ndysphagia \n \nMajor Surgical or Invasive Procedure:\nUpper endoscopy ___\n\n \nHistory of Present Illness:\n ___ w/ anxiety and several years of dysphagia who p/w worsened \nforeign body sensation. \n\nShe describes feeling as though food gets stuck in her neck when \nshe eats. She put herself on a pureed diet to address this over \nthe last 10 days. When she has food stuck in the throat, she \nalmost feels as though she cannot breath, but she denies trouble \nbreathing at any other time. She does not have any history of \nfood allergies or skin rashes. \n \nIn the ED, initial vitals: 97.6 81 148/83 16 100% RA \nImaging showed: CXR showed a prominent esophagus\nConsults: GI was consulted.\n\nPt underwent EGD which showed a normal appearing esophagus. \nBiopsies were taken.\n\nCurrently, she endorses anxiety about eating. She would like to \ntry eating here prior to leaving the hospital. \n\n \nPast Medical History:\n- GERD \n - Hypercholesterolemia \n - Kidney stones \n - Mitral valve prolapse \n - Uterine fibroids \n - Osteoporosis \n - Migraine headaches \n \nSocial History:\n___\nFamily History:\n+ HTN - father \n+ Dementia - father \n \n \nPhysical Exam:\n=================\nADMISSION/DISCHARGE EXAM\n=================\nVS: 97.9 PO 109 / 71 70 16 97 ra \nGEN: Thin anxious woman, lying in bed, no acute distress \nHEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI \nNECK: Supple without LAD, no JVD \nPULM: CTABL no w/c/r\nCOR: RRR (+)S1/S2 no m/r/g \nABD: Soft, non-tender, non-distended, +BS, no HSM \nEXTREM: Warm, well-perfused, no ___ edema \nNEURO: CN II-XII grossly intact, motor function grossly normal, \nsensation grossly intact \n \nPertinent Results:\n=============\nADMISSION LABS\n=============\n\n___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92 \nMCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___\n___ 08:27AM BLOOD ___ PTT-28.6 ___\n___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 \nCl-104 HCO3-22 AnGap-20\n___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 \nTotBili-1.0\n___ 08:27AM BLOOD Albumin-4.8\n=============\nIMAGING\n=============\n\nCXR ___: \nIMPRESSION: \n \nProminent esophagus on lateral view, without air-fluid level. \nGiven the patient's history and radiographic appearance, barium \nswallow is indicated either now or electively. \n \nNECK X-ray ___:\nIMPRESSION: \n \nWithin the limitation of plain radiography, no evidence of \nprevertebral soft tissue swelling or soft tissue mass in the \nneck. \n \n\nEGD: ___\n Impression: Hiatal hernia\nAngioectasia in the stomach\nAngioectasia in the duodenum\n (biopsy, biopsy)\nOtherwise normal EGD to third part of the duodenum \n\nRecommendations: - no obvious anatomic cause for the patient's \nsymptoms\n- follow-up biopsy results to rule out eosinophilic esophagitis\n- follow-up with Dr. ___ if biopsies show eosinophilic \nesophagitis \n\n \nBrief Hospital Course:\nMs. ___ is a ___ with history of GERD who presents with \nsubacute worsening of dysphagia and foreign body sensation. This \nhad worsened to the point where she placed herself on a pureed \ndiet for the last 10 days. She underwent CXR which showed a \nprominent esophagus but was otherwise normal. She was evaluated \nby Gastroenterology and underwent an upper endoscopy on ___. \nThis showed a normal appearing esophagus. Biopsies were taken. \n\nTRANSITIONAL ISSUES:\n-f/u biopsies from EGD\n-if results show eosinophilic esophagitis, follow-up with Dr. ___. \n___ for management\n-pt should undergo barium swallow as an outpatient for further \nworkup of her dysphagia\n-f/u with ENT as planned\n#Code: Full (presumed) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO BID \n\n \nDischarge Medications:\n1. Omeprazole 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n-dysphagia and foreign body sensation\n\nSECONDARY DIAGNOSIS:\n-GERD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were hospitalized at ___.\n\nYou came in due to difficulty swallowing. You had an endoscopy \nto look for any abnormalities in the esophagus. Thankfully, this \nwas normal. They took biopsies, and you will be called with the \nresults. You should have a test called a barium swallow as an \noutpatient.\n\nWe wish you all the best!\n-Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "R1310", "R0989", "K31819", "K219", "K449", "F419", "I341", "M810", "Z87891" ]

[ "R1310: Dysphagia, unspecified", "R0989: Other specified symptoms and signs involving the circulatory and respiratory systems", "K31819: Angiodysplasia of stomach and duodenum without bleeding", "K219: Gastro-esophageal reflux disease without esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "F419: Anxiety disorder, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "M810: Age-related osteoporosis without current pathological fracture", "Z87891: Personal history of nicotine dependence" ]

[ "K219", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nomeprazole / Iodine and Iodide Containing Products / \nhallucinogens\n \nAttending: ___.\n \nChief Complaint:\nLeft hip pain \n \nMajor Surgical or Invasive Procedure:\nStatus post left CRPP ___, ___\n\n \nHistory of Present Illness:\nREASON FOR CONSULT: Femur fracture\n\nHPI: ___ female presents with the above fracture s/p mechanical\nfall. This morning, pt was walking ___, when dog\npulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike, LOC or blood thinners.\nDenies numbness or weakness in the extremities. \n \nPast Medical History:\n- GERD \n - Hypercholesterolemia \n - Kidney stones \n - Mitral valve prolapse \n - Uterine fibroids \n - Osteoporosis \n - Migraine headaches \n \nSocial History:\n___\nFamily History:\n+ HTN - father \n+ Dementia - father \n \n \nPhysical Exam:\nGeneral: Well-appearing female in no acute distress.\n\nLeft Lower extremity:\n- Skin intact\n- No deformity, edema, ecchymosis, erythema, induration\n- Soft, non-tender thigh and leg\n- Full, painless ROM knee, and ankle\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a left valgus impacted femoral neck fracture and was \nadmitted to the orthopedic surgery service. The patient was \ntaken to the operating room on ___ for left closed reduction \nand percutaneous pinning of hip, which the patient tolerated \nwell. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to home with services was \nappropriate. The ___ hospital course was otherwise \nunremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweightbearing as tolerated in the left lower extremity, and will \nbe discharged on Lovenox for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion \nwas had with the patient regarding the diagnosis and expected \npost-discharge course including reasons to call the office or \nreturn to the hospital, and all questions were answered. The \npatient was also given written instructions concerning \nprecautionary instructions and the appropriate follow-up care. \nThe patient expressed readiness for discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactaid (lactase) 3,000 unit oral DAILY:PRN \n2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 \nmg-unit oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n3. Docusate Sodium 100 mg PO BID \n4. Enoxaparin Sodium 40 mg SC QHS \nRX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp \n#*30 Syringe Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet \nRefills:*0 \n6. Senna 8.6 mg PO BID \n7. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 \nmg-unit oral DAILY \n8. Lactaid (lactase) 3,000 unit oral DAILY:PRN \n9. Multivitamins 1 TAB PO DAILY \n10. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft valgus impacted femoral neck fracture\n\n \nDischarge Condition:\nAVSS\nNAD, A&Ox3\nLLE: Incision well approximated. Dressing clean and dry. Fires \nFHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP \npulse, wwp distally.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Weightbearing as tolerated left lower extremity\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Please take Lovenox daily for 4 weeks\n \nFollowup Instructions:\n___\n" ]

[ "S72012A", "W010XXA", "Y93K1", "Y92480", "K219", "E7800", "I341", "G43909", "Z87891", "Z87442", "F419", "M810", "Z7901" ]

[ "S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y93K1: Activity, walking an animal", "Y92480: Sidewalk as the place of occurrence of the external cause", "K219: Gastro-esophageal reflux disease without esophagitis", "E7800: Pure hypercholesterolemia, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "Z87891: Personal history of nicotine dependence", "Z87442: Personal history of urinary calculi", "F419: Anxiety disorder, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "Z7901: Long term (current) use of anticoagulants" ]

[ "K219", "Z87891", "F419", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ with history of coronary artery disease c/b\nischemic MR ___ DES to LCX ___, TTE ___ with mild regional LV\nsystolic dysfunction), heart failure with preserved ejection\nfraction (LVEF 50% ___, peripheral vascular disease, chronic\nkidney disease (stage IV), prior unprovoked DVT c/b severe UGIB\nwhile on AC, HTN, dyslipidemia, and T2DM who presents with\nseveral days of shortness of breath. \n\nPatients says that she first noticed rather acute onset dyspnea\nstarting ___ when trying to walk up the stairs in her home. \n\nShe had to sit down and catch her breath, whereas just days \nprior\nshe was able to mount ___ of stairs without difficulty. \nPatient denies any associated chest pain or palpitations. No\ndizziness or lightheadedness. Patient further denies any cough,\nfevers/chills, or pleuritic chest discomfort. She has not\nexperienced any symptoms consistent with orthopnea or PND. No\nincreased ___ swelling, patient notes that she has experienced\nthis in the past. \n\nPatient takes her weight nearly every day, 7lbs reported weight\ngain over the past week (154lbs -> 161lbs), which she attributes\nto eating more over the ___. She is currently\ntaking torsemide 40mg qd, no missed doses. No issues with\nabdominal bloating or constipation. No recent travel. \nPatient's\nhusband just recovered from a viral URI. \n\nIn the ED, initial VS were: 97.2 90 186/87 22 100% RA \n\nExam notable for:\nObvious bilateral wheezing.\nNo overt volume overload. \n\nEKG: NSR (92bpm), normal axis, normal PR/QRS intervals, QTc 479,\nq-waves III/aVF, TWIs III/aVF/V3/V6, submm lateral STDs, no \nSTEs.\n\nLabs showed: \nCBC 6.0>9.0/27.8<176 (PMNs 75.2%, MCV 97)\nBMP 142/4.8/105/___/2.4/189\nTrop <.01\nproBNP 4512\nVBG 7.33/40\nUA: 1.010 SG, pH 6.0, urobilinogen NEG, bilirubin NEG, leuk NEG,\nblood NEG, nitrite NEG, protein 100, glucose NEG, ketones NEG,\nRBC 1, WBC 1, few bacteria\n\nImaging showed: \nCXR ___\nFINDINGS: \nLungs are moderately well-expanded. There is an asymmetric right\nlower lung opacity, new from ___. The heart appears mildly\nenlarged and there is mild pulmonary vascular congestion. No\npleural effusion or pneumothorax. \nIMPRESSION: \nRight lower lobe opacity could represent pneumonia in the right\nclinical setting, although atelectasis or asymmetric pulmonary\nedema could account for this finding. Dedicated PA and lateral\nviews could be helpful for further assessment. \n \nConsults: NONE \n\nPatient received: \n___ 21:45 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 22:08 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 22:08 IH Ipratropium Bromide Neb 1 NEB \n___ 22:47 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 22:47 IH Ipratropium Bromide Neb 1 NEB \n___ 22:51 IV Azithromycin \n___ 22:51 IV CefTRIAXone\n___ 22:51 PO PredniSONE 60 mg\n___ 22:51 IV Furosemide 80 mg \n___ 23:01 IV CefTRIAXone 1 gm \n___ 00:13 IV Azithromycin 500 mg\n___ 00:23 PO/NG Atorvastatin 80 mg\n___ 00:23 PO/NG Carvedilol 25 mg\n___ 00:23 PO NIFEdipine (Extended Release) 60 mg \n___ 00:23 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 00:23 IH Ipratropium Bromide Neb 1 NEB\n___ 00:26 PO/NG Gabapentin 100 mg\n___ 00:44 SC Insulin 4 Units\n\nTransfer VS were: 98.2 77 141/76 18 100% 2L NC \n \nOn arrival to the floor, patient recounts the history as above. \nShe says that she feels improved after treatment in the ED, no\nongoing SOB. \n \n10-point ROS is otherwise NEGATIVE.\n\n \nPast Medical History:\nCoronary artery disease\nPeripheral vascular disease\nType II Diabetes Mellitus c/b diabetic retinopathy\nObesity\nEsophageal ring\nHypertension\nDyslipidemia\nBilateral unprovoked posterior tibial DVTs (___) off AC given\nsevere UGIB\nCKD Stage IV iso DM/HTN, secondary hyperparathyroidism\nAnemia\nGout\n \nSocial History:\n___\nFamily History:\nNiece had some sort of cancer. Father died in his ___ due to \nlung disease. Mother died in her ___ due to an unknown cause. \nNo early CAD or sudden cardiac death. No other known history of \ncancer. \n \nPhysical Exam:\n==============================\n ADMISSION PHYSICAL EXAM\n==============================\nVS: 97.5 162/93 78 16 100RA \nGENERAL: Pleasant female appearing younger than her stated age,\ntaking deep breaths while speaking \nHEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. \nNECK: JVD 10 CM. \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs. \nLUNGS: CTAB, no wheezes. \nABDOMEN: Obese abdomen, normoactive BS throughout, nondistended,\nnontender in all quadrants, no rebound/guarding, no\nhepatosplenomegaly. \nEXTREMITIES: No cyanosis, clubbing, or edema. \nPULSES: 2+ radial pulses bilaterally. \nNEURO: A&Ox3, moving all 4 extremities with purpose. \nSKIN: Warm and well perfused, no excoriations or lesions, no\nrashes. \n \n==============================\nDISCHARGE PHYSICAL EXAM\n==============================\nVS: Afeb, 144/78, HR 57, 97% RA, RR 12\nGEN: Well appearing in NAD\nNeck: No JVD appreciated\nCV: RRR no m/r/g, no carotid bruits appreciated\nPULM: CTAB no wheezes, rales, or crackles. Symmetric expansion\nEXT: warm well perfused, no pitting edema \n \nPertinent Results:\n==============================\n ADMISSION LABS\n==============================\n___ 09:37PM BLOOD WBC-6.0 RBC-2.88* Hgb-9.0* Hct-27.8* \nMCV-97 MCH-31.3 MCHC-32.4 RDW-15.1 RDWSD-52.0* Plt ___\n___ 09:37PM BLOOD Neuts-75.2* Lymphs-17.6* Monos-4.4* \nEos-1.8 Baso-0.3 Im ___ AbsNeut-4.49 AbsLymp-1.05* \nAbsMono-0.26 AbsEos-0.11 AbsBaso-0.02\n___ 06:40AM BLOOD ___ PTT-25.9 ___\n___ 09:37PM BLOOD Glucose-189* UreaN-38* Creat-2.4* Na-142 \nK-4.8 Cl-105 HCO3-20* AnGap-17\n___ 09:37PM BLOOD proBNP-4512*\n___ 09:37PM BLOOD cTropnT-<0.01\n___ 06:40AM BLOOD CK-MB-6 cTropnT-0.05*\n___ 02:01PM BLOOD CK-MB-5 cTropnT-0.04*\n___ 09:37PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3\n___ 09:41PM BLOOD ___ pO2-30* pCO2-40 pH-7.33* \ncalTCO2-22 Base XS--5\n \n==============================\n IMAGING\n==============================\nTTE ___: The left atrial volume index is mildly increased. \nThe estimated right atrial pressure is ___ mmHg. Left \nventricular wall thicknesses and cavity size are normal. There \nis mild regional left ventricular systolic dysfunction with \nbasal inferoseptal, inferior, inferolateral as well as mid \ninferior/inferoseptal wall motion abnormalities. Doppler \nparameters are most consistent with Grade II (moderate) left \nventricular diastolic dysfunction. Right ventricular chamber \nsize and free wall motion are normal. The diameters of aorta at \nthe sinus, ascending and arch levels are normal. The aortic \nvalve leaflets (3) are mildly thickened but aortic stenosis is \nnot present. There is no aortic valve stenosis. Trace aortic \nregurgitation is seen. The mitral valve leaflets are moderately \nthickened. Mild (1+) mitral regurgitation is seen. The tricuspid \nvalve leaflets are mildly thickened. There is mild pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\n IMPRESSION: 1) Mild regional LV systolic dysfunction c/w \nprior myocardial infarction in the RCA territory. 2) Grade II \nLV diastolic dysfunction.\n Compared with the prior study (images reviewed) of ___, LV \nsytolic function appears mildly less vigorous. Regional wall \nmotion abnormalities encompassess slightly greater territory. \n\nCXR PA & LAT ___: No focal consolidation or pulmonary \nedema.\n\nBILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___: \n1. Nonocclusive thrombosis of one of the paired posterior tibial \nveins in the bilateral lower extremities which appears grossly \nunchanged compared to bilateral lower extremity ultrasound ___. No new deep venous thrombosis in either \nextremity. \n2. Right ___ cyst measuring up to 1.8 cm across maximal \ndiameter is \nunchanged in size compared to ___. \n \n==============================\n MICROBIOLOGY\n==============================\n URINE CULTURE ___: ENTEROCOCCUS SP.. >100,000 CFU/mL.\n BLOOD CULTURE ___: Blood Culture: PENDING \n BLOOD CULTURE ___: Blood Culture: PENDING \n\n==============================\n DISCHARGE LABS\n==============================\n___ 05:45AM BLOOD WBC-5.1 RBC-2.57* Hgb-7.9* Hct-24.5* \nMCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 RDWSD-51.8* Plt ___\n___ 05:45AM BLOOD Glucose-144* UreaN-49* Creat-2.6* Na-147 \nK-4.0 Cl-105 HCO3-24 AnGap-___ yo F PMH CAD c/b ischemic MR ___ DES to ___ ___, TTE ___ \nwith mild regional LV systolic dysfunction), HFpEF (LVEF 50% \n___, PAD, CKD (stage IV), prior DVT c/b severe UGIV on AC, \nT2DM presents with subacute SOB, weight gain, c/f acute heart \nfailure exacerbation. She underwent diuresis with IV Lasix 80 \nmg, 120mg IV x2 with rapid improvement in subjective dyspnea. \n___ showed no acute DVT, CXR without sign of consolidation. \nGiven her improvement in dyspnea, no supplemental O2 \nrequirement, the patient was discharged w/o medication changes.\n\n# Shortness of breath\n# Hypoxia\n# acute exacerbation of chronic diastolic heart failure with \npreserved LVEF (50%)\nDry weight per pt 154 lbs. Admission weight above baseline, BNP \nelevated. Regarding trigger, suspect dietary vs uncontrolled \nBP. No EKG changes for ACS, trop negative, repeat TTE showed \nmild regional LV systolic dysfunction c/w prior myocardial \ninfarction in the RCA territory, as well as Grade II LV \ndiastolic dysfunction and similar to prior ___ TTE. Doubt PNA \ngiven CXR and lack of cough/fever, doubt PE given low Wells' \nscore 1.5, and stable repeat ___. Underwent diuresis with IV \nLasix 80 mg, 120mg IV x2 with rapid improvement in subjective \ndyspnea. Resumed home torsemide 40mg, nifedipine 60mg BID and \ncarvedilol 25mg BID. Was stable on RA prior to discharge.\n\n# Hypertension - Patient missed her antiHTN medications earlier \nday of admission. Continued home carvedilol 25mg BID and \nnifedipine 60mg BID with holding parameters. Appears that a \ntrial of ___ or spironolactone would be limited by \nhyperkalemia, so this was deferred.\n \n# Urinary frequency/urge incontinence: occurred in setting of \ndiuresis, however UCx ordered in ED did grow enterococci, likely \ncolonization. If symptoms persists would revaluate/treat.\n \nCHRONIC STABLE ISSUES\n\n# Normocytic anemia (recent baseline Hb 9.4 ___ - Hb was at \nbaseline, no signs of active bleeding. Likely multifactorial, \nanemia of chronic disease as well as decreased erythropoiten \nproduction iso CKD.\n \n# Non anion gap metabolic acidosis - Patient has intermittently \nhad a NAGMA in the past. No recent diarrhea. ___ suspect Type \nIV RTA given advanced age and history of T2DM (both of which can \ncause hyporeninemia).\n\n# Stage IV Chronic Kidney Disease (baseline Cr 2.3-2.8) - CKD \niso HTN and T2DM, Cr is currently at baseline. Low K/Phos/Na \ndiet. Continued home calcitriol, avoided nephrotoxins and \nrenally dosed all medications.\n\n# Coronary artery disease ___ DES to LCX ___: troponins were \ntrended from < 0.01 to 0.05 to 0.04 then stopped. CK-MB was \nflat. Patient deneied any chest pain. A TTE showed mild \nregional LV systolic dysfunction c/w prior myocardial infarction \nin the RCA territory and similar to prior ___ TTE. Continued \nhome aspirin 81mg qd, home carvedilol 25mg BID with holding \nparameters, home atorvastatin 80mg qHS.\n \n# Type II Diabetes Mellitus (last HbA1C 6.4% ___ - Under \nexcellent control, most recently in the pre-diabetic range.\n- Continue home 70/30 sliding scale (___t dinner if \nblood sugar over 130, 10 units 90-130, none if blood sugar under \n90) \n\n# Dyslipidemia: continued home atorvastatin\n\n# Insomnia: continued home gabapentin\n\n# Gout: continued home allopurinol\n \n==============================\n TRANSITIONAL ISSUES\n==============================\n- Discharge weight: 69.2kg\n- Discharge creatinine: 2.6\n- Discharge oral diuretic: torsemide 40mg daily\n- Transitional issue: consider outpatient epo with renal \n- Transitional issue: BP goal of 140/90 per accord or even \n130/80 per ACC/AHA ___ guidelines however anticipate difficulty \nin adding additional agents iso CKD (limits use of clonidine) \nand baseline potassium (would likely limit ___ or \nspironolactone) \n- TTE showed prior LV hypokinesis, could consider MIBI or \noutpatient pharmacological stress test\n- had some urinary retention/incontinence while undergoing IV \ndiuresis would assess for recurrent symptoms at routine \noutpatient visits\n\n#CODE: Full (confirmed) \n#CONTACT: ___ (husband) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Atorvastatin 80 mg PO QPM \n3. Calcitriol 0.5 mcg PO DAILY \n4. Carvedilol 25 mg PO BID \n5. Gabapentin 100 mg PO QHS \n6. NIFEdipine (Extended Release) 60 mg PO BID \n7. Torsemide 40 mg PO DAILY \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n10. Aspirin 81 mg PO DAILY \n11. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using 70/30 Insulin\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Calcitriol 0.5 mcg PO DAILY \n6. Carvedilol 25 mg PO BID \n7. Gabapentin 100 mg PO QHS \n8. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using 70/30 Insulin \n9. NIFEdipine (Extended Release) 60 mg PO BID \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n11. Torsemide 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n- Acute on chronic diastolic congestive heart failure\n\nSECONDARY DIAGNOSES\n- Hypertension\n- History of prior DVT\n- Anemia, NOS\n- Chronic Kidney Disease stage IV\n- Coronary Artery Disease ___ drug eluting stent\n- Diabetes Mellitus Type 2 controlled\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nYou were admitted to the hospital with shortness of breath and \nweight gain. This was likely caused by an exacerbation of your \nheart failure possibly from salty foods over the holiday. \n\nWhile you were in the hospital:\n- we gave you IV diuretics to help remove extra fluid\n- we checked for pneumonia with a chest x-ray, there was no sign \nof a pneumonia\n- we checked for signs on new clots in your legs, there was no \nnew clot\n\nNow that you are going home:\n- continue to take all of your medications as prescribed\n- monitor your salt intake, this should be no more than 2 grams \nevery day, ask your doctors for help with this if you do not \nknow how to keep track of your salt\n- continue to weigh yourself every morning, call your doctor if \nweight goes up more than 3 lbs.\n- follow-up with your primary care doctor regarding your blood \npressure and blood sugar control\n\nIt was a pleasure taking care of you!\n\nYour ___ Inpatient Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "E872", "N184", "E1122", "N2581", "I2510", "E11319", "D6489", "E785", "Z955", "Z86718", "I252", "Z2239", "G4700", "M1A9XX0", "R0902", "E1151", "Z794", "E669", "Z6831" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "E872: Acidosis", "N184: Chronic kidney disease, stage 4 (severe)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N2581: Secondary hyperparathyroidism of renal origin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "D6489: Other specified anemias", "E785: Hyperlipidemia, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z86718: Personal history of other venous thrombosis and embolism", "I252: Old myocardial infarction", "Z2239: Carrier of other specified bacterial diseases", "G4700: Insomnia, unspecified", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "R0902: Hypoxemia", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6831: Body mass index [BMI] 31.0-31.9, adult" ]

[ "I130", "E872", "E1122", "I2510", "E785", "Z955", "Z86718", "I252", "G4700", "Z794", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nfatigue, anemia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a past medical \nhistory of type-2 DM, hypertension, stage IV CKD, CAD s/p \ndistant MI and bare metal stent, stroke, recent unprovoked DVTs \non Coumadin, and recent upper GI bleeding, who was sent to ___ \nby her physician for anemia (Hgb 6.5).\n\nThe patient was admitted to ___ in ___ with unprovoked \nbilateral lower extremity DVTs. She was started on heparin as an \ninpatient, but anticoagulation was complicated by severely \nelevated PTT (>150) and upper GI bleed. Endoscopy was notable \nfor significant erythema, superficial ulceration, and gastritis \nwithout active bleeding. She was placed on BID PPI prophylaxis. \nShe was eventually bridged to Coumadin for a planned 6 month \ncourse. Her INR is managed by her rehab facility, and she is \nfollowed by Dr. ___ in ___ clinic. \n\nFor the last two weeks she has noted increasing fatigue along \nwith shortness of breath, exertional sub-sternal chest pain \nrelieved with rest, and symmetrical lower extremity swelling. \nDuring this period she reports that her appetite remained good, \nand he bowel function was normal. She denies bloody stools or \ndark stool. On ___ she presented to her PCP office from rehab \nreporting increasing shortness of breath and fatigue. She was \nfound to have a Hgb of 6.5, with an unconcerning CXR. She was \nsent to the ___ ED.\n\nIn the ED, her initial vitals were T: 97.5 P: 60 BP: 156/76 RR: \n16 SPO2: 100% RA. Exam was notable for guiac negative stool. \nImaging was notable for:\n \"1. Nonocclusive deep vein thrombosis of one of the paired \nposterior tibial veins bilaterally. The extent of thrombus \nbilaterally has decreased. No new deep venous thrombosis in \neither lower extremity. \n 2. Right complex ___ cyst.\"\n\nThe patient was transfused with 2 units of pRBCs, with \nappropriate increase in Hgb to 9.0. Following transfusion, a \nrepeat CXR was notable for pulmonary edema with bilateral \npleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix \nin the ED. The decision was made to admit the patient for anemia \nand flash pulmonary edema. \n\nOn the floor, vitals notable for T: 97.9 BP: 154/75 P: 65 R: 20 \nO2: 99RA FSBG: 76. She reports no acute complaints, and that her \nshortness of breath has resolved. She denies chest pain, \ndizziness, lightheadedness.\n \nPast Medical History:\n- hypertension \n- diabetes \n- hx CVA (cerebellar-medullary stroke in ___ \n- CAD (hx of MI in ___ BMS to circumflex and POBA ___ \n- peripheral arterial disease- claudication, followed by \nvascular, managed conservatively\n- stage IV CKD (baseline 2.1-2.6) \n- GERD/esophageal rings\n \nSocial History:\n___\nFamily History:\nNiece had some sort of cancer. Father died in his ___ due to \nlung disease. Mother died in her ___ due to an unknown cause. \nNo early CAD or sudden cardiac death. No other known history of \ncancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: ___ \nGeneral: Overweight woman, alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated \nLungs: Crackles to the mid-lungs bilaterally \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs or \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 2+ \npitting edema in dependent areas to the buttocks \nSkin: no rashes noted\nNeuro: ___ strength in deltoids, biceps, triceps, wrist \nextensors, finger extensors, hip flexors, hamstrings, \nquadriceps, gastrocs, tibialis anterior, bilaterally. Sensation \nintact bilaterally. \nPSYCH: Alert and fully oriented; normal mood and affect.\nsometimes slow to respond and responding with repetitive answers\nbut otherwise appropriate\n\nDISCHARGE PHYSICAL EXAM:\nVS: T: 97.6 BP: 150s-160s/70s-80s P: 60s-70s RR: 18 SPO2: 100RA\nGeneral: Overweight woman, alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated \nLungs: Clear to auscultation bilaterally\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs or \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+ \npitting edema in shins bilaterally\nSkin: no rashes noted\n\n \nPertinent Results:\nLABORATORY STUDIES ON ADMISSION\n=============================================\n___ 12:30PM WBC-4.4 RBC-2.03* HGB-6.5* HCT-20.6* \nMCV-102*# MCH-32.0 MCHC-31.6* RDW-16.3* RDWSD-59.6*\n___ 12:30PM ___\n___ 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7* \nIRON-61\n___ 12:30PM calTIBC-303 FERRITIN-155* TRF-233\n___ 12:30PM UREA N-42* CREAT-2.3* SODIUM-142 \nPOTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15\n___ 04:50PM LD(___)-247 TOT BILI-0.2\n___ 04:50PM HAPTOGLOB-188\n\nIMAGING: \n==============================================\nLENIs (___)\n1. Nonocclusive deep vein thrombosis of one of the paired \nposterior tibial veins bilaterally. The extent of thrombus \nbilaterally has decreased. No new deep venous thrombosis in \neither lower extremity. \n2. Right complex ___ cyst. \n\nCXR (___): \n1. New mild pulmonary edema with persistent small bilateral \npleural effusions. \n2. Severe cardiomegaly is likely accentuated due to low lung \nvolumes and patient positioning. \n\nCXR (___):\nAs compared to ___, the lung volumes have slightly \ndecreased. Signs of mild overinflation and moderate pleural \neffusions persist. Moderate cardiomegaly. Elongation of the \ndescending aorta. No pneumonia. \n\nLABORAROTY STUDIES ON DISCHARGE\n==============================================\n___ 05:45AM BLOOD WBC-3.4* RBC-2.93* Hgb-8.9* Hct-28.0* \nMCV-96 MCH-30.4 MCHC-31.8* RDW-17.5* RDWSD-59.7* Plt ___\n___ 05:45AM BLOOD ___ PTT-30.6 ___\n___ 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144 \nK-4.0 Cl-108 HCO3-25 AnGap-15\n___ 04:50PM BLOOD LD(LDH)-247 TotBili-0.2\n___ 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with a past medical \nhistory of type-2 DM, hypertension, stage IV CKD, CAD s/p \ndistant MI and bare metal stent, stroke, recent unprovoked DVTs \non Coumadin, and recent upper GI bleed, who was sent to ___ by \nher physician for anemia. \n\n# Anemia: \nPatient presented with Hgb of 6.5, down from her recent baseline \nof ~7.5 since her ___ hospitalization. Upon presentation she \nhad a new macrocytic anemia. Hemolysis labs were negative. She \nreceived two units of packed red cells with an appropriate rise \nin her Hgb to 9.0. Stool was guiac negative, with no reports of \ndark stool or blood in stool. Her hemoglobin remained stable at \nthis level, there was no overt bleeding, and her stool was guiac \nnegative. After transfusion the patient reported significant \nimprovement in her shortness of breath and fatigue. Given her \nhistory of gastritis and diverticulosis, a GI bleed was believed \nresponsible for her anemia. Patient should receive an \nEGD/colonoscopy as an outpatient. \n\n# Acute exacerbation of heart failure with preserved ejection \nfraction: \nThe patient was also found to be slightly volume overloaded, and \nwas treated with 2x40mg IV Lasix, with good urine output and \nsymptomatic improvement. Her pulmonary edema and peripheral \nedema resolved with diuresis.\n\nCHRONIC ISSUES:\n# Gastic ulceration: \nContinued on home pantoprazole BID\n\n# Hypertension:\nContinued on home nifedipine, carvadilol, lisinopril.\n\n# Stage IV Chronic Kidney Disease: \nCreatinine remained at baseline (b/l Cr 2.1-2.6) during \nadmission.\n\nTRANSITIONAL ISSUES\n======================\n--Patient's Anemia is thought to be due to slow GI bleed given \nhistory of gastritis and diverticulosis. Please schedule \nEGD/colonoscopy within the next month\n--Patient continued on Coumadin for bilateral DVTs; please \ncontinue to weigh the risks and benefits of anticoagulation \ngiven history of bleed.\n--Discharge weight: 167.7\n\n# CONTACT: ___ ___\n# CODE: full, confirmed\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 12.5 mg PO BID \n5. Lisinopril 40 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. NIFEdipine CR 30 mg PO BID \n8. Vitamin D ___ UNIT PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Gabapentin 100 mg PO QHS neuropathic pain \n11. Pantoprazole 40 mg PO Q12H \n12. Senna 8.6 mg PO BID constipation \n13. Warfarin 4 mg PO 3X/WEEK (___) \n14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n15. Furosemide 20 mg PO DAILY \n16. Polyethylene Glycol 17 g PO DAILY \n17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \n18. Warfarin 3 mg PO 4X/WEEK (___) \n19. 70/30 30 Units Dinner\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \nRX *acetaminophen 325 mg ___ tablet(s) by mouth Q6H:PRN Disp \n#*120 Tablet Refills:*0\n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n3. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet \nRefills:*0\n4. Carvedilol 12.5 mg PO BID \nRX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n5. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0\n6. Gabapentin 100 mg PO QHS neuropathic pain \nRX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 \nCapsule Refills:*0\n7. Lisinopril 40 mg PO DAILY \nRX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n8. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule \nRefills:*0\n9. NIFEdipine CR 30 mg PO BID \nRX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0\n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nRX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually \nQ5MIN:PRN Disp #*10 Tablet Refills:*0\n11. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*60 Tablet Refills:*0\n12. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth \ndaily Refills:*0\n13. Senna 8.6 mg PO BID constipation \nRX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day \nDisp #*60 Capsule Refills:*0\n14. Vitamin D ___ UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n15. Warfarin 4 mg PO 3X/WEEK (___) \nRX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet \nRefills:*0\n16. Warfarin 3 mg PO 4X/WEEK (___) \nRX *warfarin 3 mg 1 tablet(s) by mouth 4X/WEEK Disp #*30 Tablet \nRefills:*0\n17. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n18. Allopurinol ___ mg PO EVERY OTHER DAY \nRX *allopurinol ___ mg 1 tablet(s) by mouth EVERY OTHER DAY Disp \n#*30 Tablet Refills:*0\n19. 70/30 30 Units Dinner\nRX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 \nunit/mL (70-30) 30 units SC Take 30 Units before DINER Disp #*2 \nPackage Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\nAnemia\nCongestive heart failure exacerbation\n\nSecondary diagnosis:\nHypertension \nDMII on insulin \nCoronary artery disease \nStage IV chronic kidney disease\nDeep vein thrombosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure caring for you. You were admitted to the \nhospital with fatigue, chest pain, and shortness of breath. You \nwere found to have too few red blood cells (anemia). We gave you \nblood, and your symptoms improved. Additionally, you were found \nto have too much fluid in your legs and lungs. We treated you \nwith a diuretic, which helped eliminate the fluid. \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "D500", "I5023", "N184", "E118", "K2970", "Z23", "K259", "K5730", "I2510", "Z87891", "I252", "Z955", "I129", "Z794", "Z8673", "R0789", "Z86718", "R791", "T45515A", "I70218", "K222", "K219" ]

[ "D500: Iron deficiency anemia secondary to blood loss (chronic)", "I5023: Acute on chronic systolic (congestive) heart failure", "N184: Chronic kidney disease, stage 4 (severe)", "E118: Type 2 diabetes mellitus with unspecified complications", "K2970: Gastritis, unspecified, without bleeding", "Z23: Encounter for immunization", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "R0789: Other chest pain", "Z86718: Personal history of other venous thrombosis and embolism", "R791: Abnormal coagulation profile", "T45515A: Adverse effect of anticoagulants, initial encounter", "I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity", "K222: Esophageal obstruction", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I2510", "Z87891", "I252", "Z955", "I129", "Z794", "Z8673", "Z86718", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ndyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with a history of of HTN, CAD s/p DES with ischemic MR and \nsystolic dysfunction, ___ on torsemide, hx of DVT, who presents \nwith 4 days of dyspnea on exertion, leg swelling, and 10 weight \ngain.\n\nOf note, patient was seen in the Heart Failure Clinic with Dr. \n___ on ___ where she noted that she has had \npersistent dyspnea on exertion and PND after a lengthy prior \nhospitalization for DVT/GIB. At that time she was started on \n40mg po torsemide which initially improved her symptoms. \n\nOver the holiday she indulged in a high salt diet and developed \nslow-onset dyspnea on exertion. Denies any medication \nnoncompliance, chest pain, palpitations, palpitations. Describes \nPND, worsening exercise tolerance (unable to walk >50 feet) and \northopnea. \n\nIn the ED, patient was found to have 1+ bilateral lower \nextremity edema, and have bibasilar crackles on exam. Patient \nunderwent CXR, BNP, and was given one dose of IV 40mg Lasix. In \nthe ED initial vitals were: 97.8 73 199/100 18 95% RA. Prior to \ntransfer, vitals were 74 188/95 18 100% RA. Patient's labs were \nremarkable for sodium 146, Chloride 115, K 5.4, Bicarb 19, BUN \n39, Creatinine 2.3. Patient had CK 229, with MB 6, Trop < 0.01. \nPatient had BNP of 10,180. Patient also had Hgb 8.1, Hct 26.8, \nPlatelet 168, WBC 5.4. Urinalysis still pending upon discharge. \n\nEKG: notable for SR 76, with LAD, TWI in the inferior leads \nwhich appears unchanged from prior on ___\n\nOn the floor she is symptomatically improved since coming to the \nED. \n \nPast Medical History:\n- hypertension \n- diabetes \n- hx CVA (cerebellar-medullary stroke in ___ \n- CAD (hx of MI in ___ BMS to circumflex and POBA ___ \n- peripheral arterial disease- claudication, followed by \nvascular, managed conservatively\n- stage IV CKD (baseline 2.1-2.6) \n- GERD/esophageal rings\n \nSocial History:\n___\nFamily History:\nFather died in his ___ due to lung disease. Mother died in her \n___ due to an unknown cause. No early CAD or sudden cardiac \ndeath. No other known history of cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: T=98.0 BP: 168/96 HR=67 RR=16 O2 sat=100% on 2L NC \nAdmission weight 178lbs\nGENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. \nMood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.\nNECK: Supple with JVP of 8cm. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No \nthrills, lifts. \nLUNGS: Resp were unlabored, no accessory muscle use, dyspneic at \nthe end of a long sentence. Bibasilar crackles ___ up thorax, \ndiffuse wheezing. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: 2+ edema to shins. No femoral bruits. \nPULSES: Distal pulses palpable and symmetric\n\nDISCHARGE PHYSICAL EXAMINATION: \nVS: T=98.0 BP: 135/72 HR=67 RR=16 O2 sat=100% on RA\nweight: 74kg\nGENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. \nMood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.\nNECK: Supple with JVP of 7cm. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No \nthrills, lifts. \nLUNGS: Resp were unlabored, no accessory muscle use. Bibasilar \ncrackles trace, diffuse wheezing. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: dry. No femoral bruits. \nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\nADMISSION LABS\n___ 11:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.1* Hct-26.8* \nMCV-102*# MCH-30.8 MCHC-30.2* RDW-17.2* RDWSD-64.7* Plt ___\n___ 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0 \nEos-2.4 Baso-0.2 Im ___ AbsNeut-4.38 AbsLymp-0.61* \nAbsMono-0.27 AbsEos-0.13 AbsBaso-0.01\n___ 12:45PM BLOOD ___ PTT-32.9 ___\n___ 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06\n___ 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146* \nK-5.4* Cl-115* HCO3-19* AnGap-17\n___ 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 ___\n___ 07:38PM BLOOD CK-MB-6 cTropnT-<0.01\n___ 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8\n\nDISCHARGE LABS\n=====\n___ 07:10AM BLOOD WBC-3.9* RBC-2.81* Hgb-8.6* Hct-26.7* \nMCV-95 MCH-30.6 MCHC-32.2 RDW-16.0* RDWSD-56.4* Plt ___\n___ 07:10AM BLOOD ___\n___ 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144 \nK-3.9 Cl-105 HCO3-29 AnGap-14\n___ 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8\n\nIMAGING\n=====\n___ CXR\nFINDINGS: \nThere is mild pulmonary edema with superimposed region of more \nconfluent consolidation in the left upper lung. There are \npossible small bilateral pleural effusions. Moderate \ncardiomegaly is again seen as well as tortuosity of the \ndescending thoracic aorta. No acute osseous abnormalities.\n \nIMPRESSION: \nMild pulmonary edema with superimposed left upper lung \nconsolidation, potentially more confluent edema versus \nsuperimposed infection.\n\n \nBrief Hospital Course:\n___ year-old female with history of hypertension, CAD s/p DES \nwith ischemic MR and systolic dysfunction, ___, hx of DVT, who \nadmitted for CHF exacerbation.\n\n# Acute on chronic decompensated heart failure: presented in the \nsetting of high salt diet with dyspnea on exertion, decreased \nexercise tolerance, ___ edema, crackles on exam, elevated BNP to \n10K, 8lbs above dry weight and pulmonary congestion on CXR. \nLater discovered on pharmacy review that patient had not filled \ntorsemide after last outpatient Cardiology appointment where she \nwas instructed to start taking it. Troponins cycled and \nnegative. On admission, she was placed on a salt and fluid \nrestricted diet. She was diuresed with IV Lasix 80mg for 2 days \nand then transitioned to po torsemide 40mg with steady weight \ndecline and net negative fluid balance of goal -___ and \nstable renal function. Electrolytes repleted for goal Mg>2 and \nK>4. She was continued on home carvedilol 12.5mg BID, \natorvastatin 80mg daily and lisinopril 40mg daily for blood \npressure control and increased home nifedipine CR from 30 to \n60mg BID to achieve goal SBP <140. Discharged with close PCP and \n___ to monitor weights and blood pressure \ncontrol.\n\n# Hypertension: She was continued on home carvedilol 12.5mg BID, \natorvastatin 80mg daily and lisinopril 40mg daily for blood \npressure control and increased home nifedipine CR from 30 to \n60mg BID to achieve goal SBP <140. \n\n# Positive U/A: patient asymptomatic but with 32WBCs, ___, \n+bacteria (although 3 epis). Asymptomatic with no \nfevers/dysuria/malaise. Urine culture negative.\n\n# Left upper lung consolidation: infiltrate per Radiology read \non admission CXR. No cough, fevers, leukocytosis. Rereviewed \nwith on-call radiologist who favored pulmonary edema with no \nneed for repeat imaging or PNA treatment unless clinically \nindicated. Monitored without any significant clinical findings.\n\n# DVT: anticoagulated on Coumadin goal 2.0-3.0, no signs of \nthrombus on exam. Daily INR trended and continued on home \nCoumadin 5mg daily. \n\n# Anemia: no signs of external loss, specifically denying any \nmelena. Chronically anemic with baseline ___, presented with Hgb \n8. Likely ___ renal disease and ACD however elevated MCV \nindicates possible reticulocytosis. Altogether low suspicion for \nGIB so Coumadin was continued. Reticulocytes 2.4 which is \ninappropriate arguing against acute loss. Trended daily CBC with \nnoted uprising by discharge.\n\n# Chronic kidney disease, stage IV- baseline ___, likely ___ \nHTN and DM. Renally dosed medications and trended Cr with no \nsignificant change. \n# HLD: continued home atorvastatin\n# DM: held home 25U 70/30. Patient maintained on aspart ISS and \nglargine qHS with good glycemic control.\n\nTRANSITIONAL ISSUES\n==================\nCHF: diuresed with IV lasix, transitioned to po diuretics, \ndischarged home on 40mg po torsemide, to take in the AM and take \na banana. Pt complained of unilateral R-sided incomplete hearing \nloss on day of discharge- was not felt to be related to \ndiuretics but would ___.\nHTN: increased nifedipine CR to 60mg BID given elevated SBPs. \nPlease f/u at next appointments.\nAnemia: multiple prior workups showing ACD. Hgb 8s during \nadmission\nPrior DVT/PE: continued on warfarin, will need continued \nmonitoring\nDM: stopped home 70/30 while in-house and put on \naspart/glargine, discharged on home regimen\n\nDischarge weight: 74kg\nDischarge Cr: 1.9\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 12.5 mg PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Gabapentin 100 mg PO QHS neuropathic pain \n7. Lisinopril 40 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. NIFEdipine CR 30 mg PO BID \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n11. Pantoprazole 40 mg PO Q12H \n12. Polyethylene Glycol 17 g PO DAILY \n13. Senna 8.6 mg PO BID constipation \n14. Vitamin D ___ UNIT PO DAILY \n15. Warfarin 5 mg PO DAILY16 \n16. Allopurinol ___ mg PO EVERY OTHER DAY \n17. Torsemide 40 mg PO DAILY \n18. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL \n(70-30) subcutaneous 25 units with dinner \n\n \nDischarge Medications:\n1. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL \n(70-30) subcutaneous 25 units with dinner \n2. Warfarin 5 mg PO DAILY16 \n3. Vitamin D ___ UNIT PO DAILY \n4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \n5. Allopurinol ___ mg PO EVERY OTHER DAY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Docusate Sodium 100 mg PO BID \n9. Gabapentin 100 mg PO QHS neuropathic pain \n10. Lisinopril 40 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n13. Polyethylene Glycol 17 g PO DAILY \n14. Senna 8.6 mg PO BID constipation \n15. Torsemide 40 mg PO DAILY \nRX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60 \nTablet Refills:*0\n16. Pantoprazole 20 mg PO Q12H \n17. Carvedilol 25 mg PO BID \n18. NIFEdipine CR 60 mg PO BID \nRX *nifedipine 20 mg 3 capsule(s) by mouth twice daily Disp \n#*180 Capsule Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nAcute on chronic decompensated congestive Heart Failure\nHypertension\n\nSecondary Diagnoses:\nAnemia\nDiabetes mellitus\nPrior deep vein thrombosis\nChronic Kidney Disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMrs. ___, \n\n___ were admitted to ___ for treatment of your congestive \nheart failure and hypertension. ___ were given IV diuretics with \nimprovement in your symptoms, labs and exam. We increased one of \nyour blood pressure medications and continued your other home \nmedicines. \n\nIt was a pleasure taking care of ___ during your stay- we wish \n___ all the best!\n\n- Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I5023", "N184", "D631", "E1121", "Z86718", "I129", "Z955", "I2510", "Z7901", "Z794", "I340", "I252", "Z8673", "Z87891", "Z91128", "E785" ]

[ "I5023: Acute on chronic systolic (congestive) heart failure", "N184: Chronic kidney disease, stage 4 (severe)", "D631: Anemia in chronic kidney disease", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "Z86718: Personal history of other venous thrombosis and embolism", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z955: Presence of coronary angioplasty implant and graft", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "I340: Nonrheumatic mitral (valve) insufficiency", "I252: Old myocardial infarction", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "E785: Hyperlipidemia, unspecified" ]

[ "Z86718", "I129", "Z955", "I2510", "Z7901", "Z794", "I252", "Z8673", "Z87891", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nBladder cancer\n \nMajor Surgical or Invasive Procedure:\nrobotic anterior exenteration and open ileal conduit\n\n \nHistory of Present Illness:\n___ with invasive bladder cancer, pelvic MRI concerning for \ninvasion into anterior vaginal wall, now s/p robotic anterior \nexent (Dr ___ and open ileal conduit (Dr ___.\n \nPast Medical History:\nHypertension, laparoscopic cholecystectomy\nsix months ago, left knee replacement six to ___ years ago,\nlaminectomy of L5-S1 at age ___, two vaginal deliveries.\n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nA&Ox3\nBreathing comfortably on RA\nWWP\nAbd S/ND/appropriate postsurgical tenderness to palpation\nUrostomy pink, viable\n \nPertinent Results:\n___ 06:50AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-32.5* \nMCV-95 MCH-31.1 MCHC-32.6 RDW-14.4 RDWSD-50.2* Plt ___\n___ 06:50AM BLOOD Plt ___\n___ 06:45AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-136 \nK-4.4 Cl-104 HCO3-23 AnGap-13\n___ 06:45AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ was admitted to the Urology service after \nundergoing [robotic anterior exenteration with ileal conduit]. \nNo concerning intrao-perative events occurred; please see \ndictated operative note for details. Patient received \n___ intravenous antibiotic prophylaxis and deep vein \nthrombosis prophylaxis with subcutaneous heparin. The \npost-operative course was notable for several episodes of emesis \nprompting NGT placement on ___. Pt self removed the NGT on ___, \nbut nausea/emesis resolved thereafter and pt was gradually \nadvanced to a regular diet with passage of flatus without issue. \n With advacement of diet, patient was transitioned from IV pain \nmedication to oral pain medications. The ostomy nurse\nsaw the patient for ostomy teaching. At the time of discharge \nthe wound was healing well with no evidence of erythema, \nswelling, or purulent drainage. Her drain was removed. The \nostomy was perfused and patent, and one ureteral stent had \nfallen out spontaneously. ___ was consulted and recommended \ndisposition to rehab. Post-operative follow up appointments \nwere arranged/discussed and the patient was discharged to rehab \nfor further recovery.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Heparin 5000 UNIT SC ONCE \nStart: in O.R. Holding Area \n2. Losartan Potassium 50 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. Levothyroxine Sodium 175 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \ntake while taking narcotic pain meds \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*50 Capsule Refills:*0 \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe \nRefills:*0 \n4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \ntake while ureteral stents are in place \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth daily Disp #*14 Capsule Refills:*0 \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*30 Tablet \nRefills:*0 \n6. Atorvastatin 10 mg PO QPM \n7. Levothyroxine Sodium 175 mcg PO DAILY \n8. Losartan Potassium 50 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nBladder cancer\n\n \nDischarge Condition:\nWdWn, NAD, AVSS\nAbdomen soft, appropriately tender along incision\nIncision is c/d/I (steris)\nStoma is well perfused; Urine color is yellow\nUreteral stent noted via stoma\nJP drain has been removed\nBilateral lower extremities are warm, dry, well perfused. There \nis no reported calf pain to deep palpation. No edema or pitting\n\n \nDischarge Instructions:\n-Please also refer to the handout of instructions provided to \nyou by your Urologist\n-Please also refer to the instructions provided to you by the \nOstomy nurse specialist that details the required care and \nmanagement of your Urostomy\n-You will be sent home with Visiting Nurse ___ \nservices to facilitate your transition to home care of your \nurostomy\n-Resume your pre-admission/home medications except as noted. \nAlways call to inform, review and discuss any medication changes \nand your post-operative course with your primary care doctor\n-___ you have been prescribed IBUPROFEN, please note that you may \ntake this in addition to the prescribed NARCOTIC pain \nmedications and/or tylenol. FIRST, alternate Tylenol \n(acetaminophen) and Ibuprofen for pain control.\n-REPLACE the Tylenol with the prescribed narcotic if the \nnarcotic is combined with Tylenol (examples include brand names \n___, Tylenol #3 w/ codeine and their generic \nequivalents). ALWAYS discuss your medications (especially when \nusing narcotics or new medications) use with the pharmacist when \nyou first retrieve your prescription if you have any questions. \nUse the narcotic pain medication for break-through pain that is \n>4 on the pain scale.\n-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from \nALL sources) PER DAY and remember that the prescribed narcotic \npain medication may also contain Tylenol (acetaminophen) so this \nneeds to be considered when monitoring your daily dose and \nmaximum.\n-If you are taking Ibuprofen (Brand names include ___ \nthis should always be taken with food. If you develop stomach \npain or note black stool, stop the Ibuprofen.\n-Please do NOT drive, operate dangerous machinery, or consume \nalcohol while taking narcotic pain medications.\n-Do NOT drive and until you are cleared to resume such \nactivities by your PCP or urologist. You may be a passenger\n-Colace may have been prescribed to avoid post surgical \nconstipation and constipation related to narcotic pain \nmedication. Discontinue if loose stool or diarrhea develops. \nColace is a stool-softener, NOT a laxative.\n-You may shower 2 days after surgery, but do not tub bathe, \nswim, soak, or scrub incision for 2 weeks\n-If you had a drain or skin clips (staples) removed from your \nabdomen; bandage strips called “steristrips” have been applied \nto close the wound OR the site was covered with a gauze \ndressing. Allow any steristrips/bandage strips to fall off on \ntheir own ___ days). PLEASE REMOVE any \"gauze\" dressings within \ntwo days of discharge. Steristrips may get wet.\n-No heavy lifting for 4 weeks (no more than 10 pounds). Do \"not\" \nbe sedentary. Walk frequently. Light household chores (cooking, \nfolding laundry, washing dishes) are generally “ok” but AGAIN, \navoid straining, pulling, twisting (do NOT vacuum).\n\n \nFollowup Instructions:\n___\n" ]

[ "C675", "I10", "D259", "Z87891", "E785", "E890" ]

[ "C675: Malignant neoplasm of bladder neck", "I10: Essential (primary) hypertension", "D259: Leiomyoma of uterus, unspecified", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "E890: Postprocedural hypothyroidism" ]

[ "I10", "Z87891", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\n dyspnea on exertion \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ year old woman s/p robotic radical cystectomy \n___ (with ileal conduit creation) with postop course \ncomplicated by bacteremia and abscess, LLE DVT (on prophylactic \ndosing lovenox) who presents with dyspnea on exertion for past 3 \ndays. \n\nBriefly, patient was initially admitted to the Urology service \nfrom ___ for robotic anterior exenteration with ileal \nconduit. She was discharged to rehab on prophylactic dosing \nlovenox for 1 month. She was then readmitted from ___ for \nileus requiring NGT decompression, TPN. BCx grew Citrobacter, \nfor which CTX was started. CT showed intra-abdominal, interloop, \nsimple fluid collection and LLQ drain was placed by ___. Patient \nimproved, passing BMs and tolerating PO, and was discharged on \ncipro/flagyl. She was also discharged on PO Bactrim for presumed \nUTI, though unclear if she actually took this. During this \nadmission, she was noted to have new bilateral ___ edema. LENIs \nat the time showed aute deep vein thrombosis of the duplicated \nmid and distal left femoral veins. She was discharged on \nEnoxaparin Sodium 40 mg SC daily. She reports that her PCP \nstarted PO ___ 20mg daily and since then there has been \nimprovement of the swelling. Per her report, a repeat ___ at \nthe rehab facility (___) was negative for DVT.\n\nPatient reports that she recovered well post-operatively and was \ndoing well at her assisted living facility up until a week ago \nwhen she began experiencing dyspnea on exertion. She states that \nshe typically is able to ambulate a block before stopping to \ncatch her breath, however in the past week she has been unable \nto take more than a few steps. She states that it has become \nincreasingly more difficult to ambulate from her bedroom to the \nbathroom. When visited by the NP her ambulatory saturation was \nnoted to be in the ___ with associated tachycardia to 110, \npallor and diaphoresis. She endorses associated leg swelling \nleft worse than right, and she states that her thighs \"feel \nheavy\". She denies any associated chest pain, fever, chills, \npain with deep inspiration, abdominal pain, rashes, dizziness, \nlightheadedness. \n\nIn the ED, initial VS were: 97.7 72 136/93 20 100% Nasal Cannula \n\nED physical exam was recorded as patient resting comfortably \nwith NC, pursed lip breathing, unable to speak in full sentences \nbefore becoming short of breath, urostomy pouch in RLQ, stoma \npink, 2+ edema to bilateral lower extremities L>R. \n\nED labs were notable for: Hb 9, Hct 29, plt 479, UA: large ___, \n>182 WBC, many bact 0 epi. Trop neg x1, proBNP normal\n\nCTA chest showed:\n1. Extensive pulmonary embolism with thrombus seen extending \nfrom the right main pulmonary artery into the segmental and \nsubsegmental right upper, middle, and lower lobe pulmonary \narteries. No right heart strain identified. 2. Additionally, \nthere are smaller pulmonary emboli seen in the segmental and \nsubsegmental branches of the left upper and lower lobes. 3. \nSeveral pulmonary nodules are noted, as noted previously, with \nthe largest appearing spiculated and measuring up to 1 cm in the \nright middle lobe, suspicious for malignancy on the previous \nPET-CT. 4. Re- demonstration of 2 left breast nodules for which \ncorrelation with mammography and ultrasound is suggested.\n\nEKG showed NSR with frequent PAC\n\nPatient was given:\n___ 20:26 PO/NG Ciprofloxacin HCl 500 mg \n___ 20:26 IV Heparin 6600 UNIT \n___ 20:26 IV Heparin \n\nTransfer VS were: 98.1 77 145/63 20 99% Nasal Cannula \n When seen on the floor, she reports significant dyspnea with \nminimal exertion. Denies chest pain, palpitations, \nlightheadedness.\nA ten point ROS was conducted and was negative except as above \nin the HPI.\n \nPast Medical History:\nHypertension, laparoscopic cholecystectomy, left knee \nreplacement six to ___ years ago, laminectomy of L5-S1 at age \n___, two vaginal deliveries.\n\ns/p ___: \n1. Robot-assisted laparoscopic bilateral pelvic lymph node \ndissection.\n2. Robot-assisted hysterectomy and bilateral oophorectomy for \nlarge uterus, greater than 300 grams, with large fibroid.\n3. Laparoscopic radical cystectomy and anterior vaginectomy with \nvaginal reconstruction.\n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nADMISSION EXAM:\n Gen: NAD, speaking in 3 word sentences, pursed lip breathing, \nno accessory muscle use, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, 1+ edema bilaterally with \ncompression stockings in place, no JVD \n Resp: normal effort, no accessory muscle use, lungs CTA ___ to \nanterior auscultation.\n GI: soft, NT, ND, BS+. Urostomy site does not appear infected\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect \n\nDISCHARGE EXAM:\nvitals: 98.3 140/42 90 24 96% 1L\nGen: Lying in bed in no apparent distress\nHEENT: Anicteric, MMM\nCardiovascular: RRR normal S1, S2, no right sided heave, ___ \nsystolic murmur \nPulmonary: Lung fields clear to auscultation throughout. No \ncrackles or wheezing. \nGI: Soft, distended, nontender, bowel sounds present, urostomy \nin place.\nExtremities: no edema, though left leg appears larger than right \nleg, warm, well perfused with motor function intact. Her left \nlower leg is wrapped. \n\n \nPertinent Results:\nLABS:\n==========================\nAdmission labs:\n___ 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136 \nPOTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20\n___ 02:40PM cTropnT-<0.01\n___ 02:40PM proBNP-567\n___ 02:40PM WBC-7.7 RBC-3.07* HGB-9.0* HCT-29.1* MCV-95 \nMCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-52.1*\n___ 02:40PM PLT COUNT-479*\n___ 02:40PM ___ PTT-33.4 ___\n\nDischarge labs:\n___ 06:55AM BLOOD WBC-11.0* RBC-2.60* Hgb-7.5* Hct-24.5* \nMCV-94 MCH-28.8 MCHC-30.6* RDW-14.8 RDWSD-51.4* Plt ___\n___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141 \nK-4.3 Cl-105 HCO3-26 AnGap-14\n___ 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0\n___ 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103*\n___ 07:15AM BLOOD Iron-18*\n\nMICROBIOLOGY\n==========================\n___ 4:30 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n ENTEROCOCCUS SP.. >100,000 CFU/mL. \n PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- <=1 S\nVANCOMYCIN------------ 1 S\n\nIMAGING\n==========================\n___ CXR\nIMPRESSION: Hilar congestion without frank edema. No convincing \nsigns of pneumonia.\n\n___ CTA chest showed:\n1. Extensive pulmonary embolism with thrombus seen extending \nfrom the right main pulmonary artery into the segmental and \nsubsegmental right upper, middle, and lower lobe pulmonary \narteries. No right heart strain identified. 2. Additionally, \nthere are smaller pulmonary emboli seen in the segmental and \nsubsegmental branches of the left upper and lower lobes. 3. \nSeveral pulmonary nodules are noted, as noted previously, with \nthe largest appearing spiculated and measuring up to 1 cm in the \nright middle lobe, suspicious for malignancy on the previous \nPET-CT. 4. Re- demonstration of 2 left breast nodules for which \ncorrelation with mammography and ultrasound is suggested.\n\n___ ___:\nIMPRESSION:\n1. Interval progression of deep vein thrombosis in the left \nlower extremity, with occlusive thrombus involving the entire \nfemoral vein, previously only involving the mid and distal \nfemoral vein. There is additional nonocclusive thrombus in the \ndeep femoral vein. The left common femoral and popliteal veins \nare patent.\n2. The bilateral calf veins were not visualized due to an \noverlying dressing. Otherwise no evidence of deep venous \nthrombosis in the right lower extremity.\n\n___ TTE:\nConclusions\nThe left atrium is normal in size. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thickness, cavity \nsize, and global systolic function are normal (LVEF>55%). \nDoppler parameters are most consistent with Grade I (mild) left \nventricular diastolic dysfunction. Right ventricular chamber \nsize and free wall motion are normal. The aortic valve leaflets \nare mildly thickened (?#). There is no aortic valve stenosis. \nTrivial mitral regurgitation is seen. There is mild pulmonary \nartery systolic hypertension. \n\n___ CXR\nIMPRESSION: \nCompared to chest radiographs ___ through ___. \nHeart size top-normal. Lungs grossly clear. No pleural \nabnormality or evidence of central lymph node enlargement.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman s/p robotic radical cystectomy \n___omplicated by bacteremia and \nabscess, LLE DVT, currently on daily lovenox who presents with \ndyspnea on exertion and dyspnea on exertion and found to have \nlarge PE and progression of DVT.\n\n# PE/DVT: Likely due to undertreatment of known LLE DVT with \nprophylactic dosing of lovenox. Given underdosing of lovenox, \nthis was not thought to be treatment failure and IVC filter was \ndeferred. She had no signs of right heart strain on imaging, \nEKG, exam. TTE showed no evidence of right heart strain. She was \ntreated with a heparin gtt, then transitioned to treatment dose \nlovenox given malignancy associated thrombosis as noted in CLOT \ntrial. She is quite symptomatic and requires oxygen \nsupplementation, though improved during hospitalization. Please \nwean oxygen as tolerated.\n\n# Pulmonary nodules: Known spiculated masses that were noted on \nCT in ___, concerning for primary lung malignancy vs mets. \nCurrent CT showed stable nodules still concerning for \nmalignancy. She was evaluated by the thoracic team who \nrecommended CT biopsy vs. surveillance. Given her current \nPE/DVT, the family and the patient decided for surveillance at \nthis time. They will follow up with her primary care provider. \n\n# Enterococcal UTI\nShe was noted to have rising WBC in the setting of UCX from \nurostomy growing Enterococcus. Given her rising leukocytosis, we \nproceeded with treatment. She was started on IV Ampicillin and \ntransitioned to macrobid, based on sensitivies. Leukocytosis \nimproved on antibiotics. She should complete a 7 day course (day \n1: ___, day 7: ___. \n\n# Normocytic Anemia: No signs of bleeding, or hemolysis. Hb \ndropped to nadir of 7.3, stable at discharge at 7.5. Iron \nstudies consistent with likely combination iron deficiency \nanemia and anemia of chronic disease with low iron but elevated \nferritin and low TIBC. Would recommend checking again as \noutpatient and work-up as needed.\n\n# ___ swelling: Likley multifactorial including venous \ninsufficiency, as well as known LLE DVT. She responded quite \nwell with compression stockings.\n\n# Hx of bladder cancer: s/p ___ TURBT, high-grade TCC, T1 \n(no muscle identified). Then in ___, pelvic MRI showed \nbladder mass invasion, perivesical soft tissue, anterior vaginal \nwall on right (C/W T4 lesion). In ___, underwent robotic \nTAH-BSO, lap radical cystectomy and anterior vaginectomy with \npathology showing pT2b, node and margins negative. No plan for \nany further therapy at this time per Dr ___.\n\nThe patient is safe to discharge today, and >30min were spent on \ndischarge day management services.\n\nTransitional issues:\n- She will need follow up chest CT for pulmonary nodules in 3 \nmonths (___)\n- To complete 7 day course for UTI with macrobid (day 7: ___\n- Continue oxygen therapy and wean as tolerated to maintain O2 \nsat > 92% \n- Please check CBC on ___ to ensure stability of h/h \nand demonstrate resolution of leukocytosis\n- HCP: son, Dr. ___ ___\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 650 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n4. Levothyroxine Sodium 175 mcg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Losartan Potassium 50 mg PO DAILY \n7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n8. LORazepam 0.25 mg PO BID:PRN anxiety \n9. Senna 8.6 mg PO BID \n\n \nDischarge Medications:\n1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H \nLast day: ___. Enoxaparin Sodium 90 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n3. LORazepam 0.25 mg PO QHS:PRN insomnia \nRX *lorazepam 0.5 mg 0.5 (One half) tab by mouth QHS:prn Disp \n#*3 Tablet Refills:*0 \n4. Acetaminophen 650 mg PO Q6H \n5. Atorvastatin 10 mg PO QPM \n6. Docusate Sodium 100 mg PO BID \n7. Levothyroxine Sodium 175 mcg PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:prn Disp #*3 Tablet \nRefills:*0 \n9. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPE\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nMs. ___ it was a pleasure taking care you during your \nadmission to ___. You were admitted for a clot in your lungs \nand leg. You were treated with a blood thinner. You will need to \ncontinue the blood thinner. You were also treated for a urinary \ntract infection. For your pulmonary nodules, you should follow \nup with your primary care doctor. \n \nFollowup Instructions:\n___\n" ]

[ "I2699", "I82412", "N390", "I471", "I10", "I872", "R918", "B952", "E039", "E785", "E876", "E8342", "G4700", "K5900", "Z66", "N63", "D509", "D638", "Z7901", "Z8551", "Z906", "Z87891", "Z96652" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "I82412: Acute embolism and thrombosis of left femoral vein", "N390: Urinary tract infection, site not specified", "I471: Supraventricular tachycardia", "I10: Essential (primary) hypertension", "I872: Venous insufficiency (chronic) (peripheral)", "R918: Other nonspecific abnormal finding of lung field", "B952: Enterococcus as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "E876: Hypokalemia", "E8342: Hypomagnesemia", "G4700: Insomnia, unspecified", "K5900: Constipation, unspecified", "Z66: Do not resuscitate", "N63: Unspecified lump in breast", "D509: Iron deficiency anemia, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "Z7901: Long term (current) use of anticoagulants", "Z8551: Personal history of malignant neoplasm of bladder", "Z906: Acquired absence of other parts of urinary tract", "Z87891: Personal history of nicotine dependence", "Z96652: Presence of left artificial knee joint" ]

[ "N390", "I10", "E039", "E785", "G4700", "K5900", "Z66", "D509", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, distention, nausea\n \nMajor Surgical or Invasive Procedure:\nInterventional radiology placement of abdominal abscess drain\n\n \nHistory of Present Illness:\n___ F with h/o muscle invasive bladder cancer, returning to \nthe ED POD 15 with abdominal pain, nausea, and distension. She \nhas been obstipated for nearly three days. KUB and CT scan \nnotable for dilated loops, air fluids, and tapering small bowel \nwithout an obvious transition point. Labwork notable for ___ \nand\nleukocytosis. Concerned for small bowel obstruction or an ileus \nin presence ___ and leukocytosis she was re-admitted for IVF, \nbowel rest, NGT decompression. \n \nPast Medical History:\nHypertension, laparoscopic cholecystectomy, left knee \nreplacement six to ___ years ago, laminectomy of L5-S1 at age \n___, two vaginal deliveries.\n\ns/p ___: \n1. Robot-assisted laparoscopic bilateral pelvic lymph node \ndissection.\n2. Robot-assisted hysterectomy and bilateral oophorectomy for \nlarge uterus, greater than 300 grams, with large fibroid.\n3. Laparoscopic radical cystectomy and anterior vaginectomy with \nvaginal reconstruction.\n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nWdWn, NAD, AVSS\nAbdomen soft, appropriately tender along incision\nIncision is c/d/I\nStoma is well perfused; Urine color is yellow\nBilateral lower extremities are warm, dry, well perfused. There \nis no reported calf pain to deep palpation. Bilateral lower \nextremities have 2+ pitting edema but no erythema, callor, pain. \n\nPigtail drain has been removed - dressing c/d/i\n \nPertinent Results:\n___ 05:58AM BLOOD WBC-9.9 RBC-2.76* Hgb-8.2* Hct-26.2* \nMCV-95 MCH-29.7 MCHC-31.3* RDW-13.9 RDWSD-47.3* Plt ___\n___ 06:45AM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.7* \nMCV-97 MCH-30.3 MCHC-31.4* RDW-14.0 RDWSD-49.4* Plt ___\n___ 05:13AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.8* Hct-31.0* \nMCV-95 MCH-30.0 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt ___\n___ 07:06PM BLOOD WBC-22.5*# RBC-3.58* Hgb-10.9* Hct-34.0 \nMCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 RDWSD-47.9* Plt ___\n___ 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3* \nEos-0 Baso-0 ___ Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48* \nAbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00*\n___ 01:04PM BLOOD ___ PTT-30.9 ___\n___ 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136 \nK-4.6 Cl-107 HCO3-26 AnGap-8\n___ 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137 \nK-4.1 Cl-106 HCO3-25 AnGap-10\n___ 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140 \nK-3.6 Cl-107 HCO3-26 AnGap-11\n___ 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133 \nK-5.0 Cl-96 HCO3-21* AnGap-21*\n___ 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77\n\n___ 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2\n___ 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1\n\n___ 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1 \nIron-23*\n___ 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2\n___ 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89*\n___ 05:09AM BLOOD Triglyc-106\n___ 08:30AM BLOOD Triglyc-89\n\n___ 07:06PM BLOOD Lactate-1.5\n\n___ 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29 \nLipase-8\n___ 03:00PM OTHER BODY FLUID Creat-0.5\n\n___ 7:12 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n CITROBACTER KOSERI. FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n CITROBACTER KOSERI\n | \nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM NEGATIVE ROD(S). \n Reported to and read back by ___ ___, @14:35 ON \n___. \n\n___ 3:00 pm ABSCESS . PELVIC ASPIRATION. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n WOUND CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: \n BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. \n BETA LACTAMASE POSITIVE. \n\n___ 10:52 am STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\n \nBrief Hospital Course:\nMs. ___ was admitted to Dr. ___ service for \nmanagement of ileus. Upon admission, a nasogastric tube was \nplaced for decompression. On ___, PICC was placed and TPN \nstarted. Blood cultures grew gram negative rods and ceftriaxone \nwas started. On ___, pt started to pass small amount of \nflatus. ___ CT scan demonstrated improving ileus, but concern \nfor possible urine leak and increased free fluid. On ___, a \nLLQ drain was placed by interventional radiology. on ___, pt \npassed clamp trial and NGT was removed. Pt continued to pass \nflatus and also started to have bowel movements. On ___, pt \nwas advanced to a clear liquid diet. Repeat blood cultures were \nnegative and positive blood culture from admission grew \ncitrobacter. Diet was gradually advanced and ensure added. IV \nmedications were gradually converted to PO and she was \nre-evaluated by physical therapy for rehabilitative services. \nShe was ambulating with walker assistance and prepared for \ndischarge to her ___ facility (___). TPN was \ncontinued up until day before discharge. At time of discharge, \nshe was tolerating regular diet, passing flatus regularly and \nhaving bowel movements. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. Levothyroxine Sodium 175 mcg PO DAILY \n3. Losartan Potassium 50 mg PO DAILY \n4. Acetaminophen 650 mg PO Q6H \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC DAILY \n7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nLast dose ___ \n2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days \nLast dose ___ \n3. Senna 8.6 mg PO BID \n4. Acetaminophen 650 mg PO Q6H \n5. Atorvastatin 10 mg PO QPM \n6. Docusate Sodium 100 mg PO BID \n7. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n8. Levothyroxine Sodium 175 mcg PO DAILY \n9. LORazepam 0.25 mg PO BID:PRN anxiety \n10. Losartan Potassium 50 mg PO DAILY \n11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \n12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nbladder cancer, post-operative ileus, bacteremia (CITROBACTER \nKOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS \nGROUP) requiring ___ drainage\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n-Please also refer to the instructions provided to you by the \nOstomy nurse specialist that details the required care and \nmanagement of your Urostomy\n\n-Resume your pre-admission/home medications except as noted. \nAlways call to inform, review and discuss any medication changes \nand your post-operative course with your primary care doctor\n\n-___ (acetaminophen) and Ibuprofen for pain control.\n\n-Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications \nto treat your infection. Continue for 7 days through ___.\n\n-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from \nALL sources) PER DAY \n\n-If you are taking Ibuprofen (Brand names include ___ \nthis should always be taken with food. If you develop stomach \npain or note black stool, stop the Ibuprofen.\n\n-Please do NOT drive, operate dangerous machinery, or consume \nalcohol while taking narcotic pain medications.\n\n-Do NOT drive and until you are cleared to resume such \nactivities by your PCP or urologist. You may be a passenger\n\n-Colace may have been prescribed to avoid post surgical \nconstipation and constipation related to narcotic pain \nmedication. Discontinue if loose stool or diarrhea develops. \nColace is a stool-softener, NOT a laxative.\n\n-No heavy lifting for 4 weeks (no more than 10 pounds). Do \"not\" \nbe sedentary. Walk frequently. Light household chores (cooking, \nfolding laundry, washing dishes) are generally “ok” but AGAIN, \navoid straining, pulling, twisting (do NOT vacuum).\n\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "K651", "N179", "I82412", "C679", "I10", "B966", "R7881", "Y838", "Y9289", "F17210", "Z436", "Z90710", "D72829", "Z96652" ]

[ "T814XXA: Infection following a procedure", "K651: Peritoneal abscess", "N179: Acute kidney failure, unspecified", "I82412: Acute embolism and thrombosis of left femoral vein", "C679: Malignant neoplasm of bladder, unspecified", "I10: Essential (primary) hypertension", "B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere", "R7881: Bacteremia", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y9289: Other specified places as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z436: Encounter for attention to other artificial openings of urinary tract", "Z90710: Acquired absence of both cervix and uterus", "D72829: Elevated white blood cell count, unspecified", "Z96652: Presence of left artificial knee joint" ]

[ "N179", "I10", "F17210" ]

[]

[" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: (...TRUNCATED)

["T8140XA","A4181","R6520","N179","N1330","N12","T8144XA","Z936","I10","E785","E039","Z87891","Z8551(...TRUNCATED)

["T8140XA: Infection following a procedure, unspecified, initial encounter","A4181: Sepsis due to En(...TRUNCATED)

[ "N179", "I10", "E785", "E039", "Z87891", "Z86718" ]

[]